CMS Occupancy Classifications

From ASHE.org - In The Spotlight

Pending CMS Revision to S&C Letter on Occupancy Classifications
On December 17, 2010, CMS issued a Survey and Certification letter updating its occupancy classifications to ensure alignment with the 2000 edition of NFPA 101: Life Safety Code. As a result of the content of this update-S&C 11-05-LSC-ASHE has been receiving numerous telephone calls, e-mails, and traffic on the LISTSERV® about the potential impact this "clarification" could have on our members' clinics and medical office buildings.

Compliance News: Risk of Suicides in Hospital ER and Inpatient Units

By Dean Samet, CHSP



The Joint Commission issued a Sentinel Event Alert in its warning of the increased number of reported non-psychiatric patients committing suicide in hospital emergency rooms/departments and medical/surgical inpatient units. Suicide has ranked in the top five most frequently reported events to The Joint Commission in the past 15 years and ranks number 11 by the Centers for Disease Control and Prevention (CDC) as a leading cause of death in the nation.

Compliance News: Environment of Care Time Notations

By Dean Samet, CHSP



The Joint Commission has a number of time notations designated in the Environment of Care standards’ elements of performance for its expectations when certain inspections, tests, tasks, functions, events, or drills are to occur. TJC recognizes that it will not always be possible to meet the exact time frames cited in their EPs. Therefore, as delineated in the November 2010 Environment of Care News article Time Defined, TJC has provided the following definitions which include some leeway and allowable deviation.

Compliance News: Manufacturer's Maintenance Recommendations - Alternatives Accepted by CMS

By Dean Samet, CHSP


The Joint Commission accredited hospitals, critical access hospitals, and ambulatory care programs can breathe a sigh of relief.  As reported in the December 2010 The Joint Commission Perspectives®, TJC engaged the Centers for Medicare & Medicaid Services (CMS) in a collaborative exchange to explain its viewpoint on why it is important to allow health care organizations to continue to employ TJC standards’ three criteria for scheduled maintenance activities for medical equipment and for utility systems.


The criteria consist of manufacturer’s recommendations, risk levels associated with the equipment, as well as hospital experience (see applicable TJC standards and elements of performance below along with yet to be revised CMS Interpretive Guidelines).  According to the Perspectives article, CMS agreed!

Compliance News: TJC News Brief on Shortened Survey Time Frame

By Dean Samet, CHSP


The Joint Commission announced in the November 17, 2010 Joint Commission Online that effective Jan. 1, 2011, full survey time frames will change from 39 to 36 months (see note below) for all accreditation programs (except the laboratory accreditation program). TJC will conduct an organization’s full survey within 36 months instead of 39 months after its previous full survey primarily to maintain consistency in the timing of the survey window with the Centers for Medicare & Medicaid Services (CMS).


Note: Previously, per the 2010 Hospital Accreditation Standards manual, The Accreditation Process chapter, section Duration of Accreditation Award, “An accreditation award is continuous until the organization has its next full survey, which will be between 18-39 months after its previous full survey, unless accreditation is revoked for cause or as otherwise outlined in this chapter.” In the same chapter under the Duration of the Accreditation Decision, “An organization’s previous accreditation decision remains in effect until a decision is made either to accredit or to preliminarily deny accreditation to the organization.”

Current Technologies Are Vastly Different Than The Technologies In Place When Most Mechanical Engineers Started

By J. Patrick Banse, PE, LEED AP, Smith Seckman Reid Inc., Houston

When mechanical engineers are in school, few of them know exactly where their degree might take them. I was one of those engineers. Being exposed to many aspects of this fascinating engineering program, I was awed by the range of career choices—steam and power generation, automotive design, structures. However, only a few courses—thermodynamics, fluid dynamics, and heat transfer—prepared me for the area I ended up in, partially by choice but mostly by having mentors that instilled a passion in me that continues to guide me more than 35 years after graduation. The area of mechanical engineering I ended up in was HVAC, plumbing, and fire protection design in buildings, specifically healthcare, but that was after a few years of preliminaries and, as I found out, nothing like I learned in school.

Read entire article here: Current Technologies Are Vastly Different

Ready for tomorrow - Six critical areas of emergency power management

By David L. Stymiest, P.E., CHFM, FASHE (in Health Facilities Management)

An emergency power (EP) system's role in patient safety is critical to hospitals and regulators. Each hospital EP system must power what the health care facility needs, when and for as long as it needs it.
That is a tall order and one that likely will become more complicated as new requirements and technologies increase the demands on these systems.

So, how can hospitals prepare for these challenges? What measures should they take? Of what dangers should they be aware? These questions can be answered by exploring and analyzing six critical areas of emergency power management.

Read entire article here:  Ready for tomorrow

Compliance News: Location of the Master and Ancillary Fire Alarm Panels

By Dean Samet, CHSP


In a July 2010 Environment of Care News article entitled, Ensuring Effective Fire Alarm and Automatic Sprinkler Systems, The Joint Commission says that there has been some confusion among health care organizations regarding the requirements for the master fire alarm panel location. 

Compliance News: Manual Transmission of Fire Alarm Signals Permitted Under Certain Conditions by TJC

By Dean Samet, CHS

 

In the July 2010 Environment of Care News article Ensuring Effective Fire Alarm and Automatic Sprinkler Systems, The Joint Commission (TJC) reintroduced a manual method of fire alarm transmission policy. This policy is meant to be applied when the four traditional methods of transmitting fire alarm signals to the local fire department cannot be achieved per the 2000 NFPA 101, Life Safety Code® (LSC), Section 9.6.4 Emergency Forces Notification, which in turn references the 1999 NFPA 72, National Fire Alarm Code®. 

Compliance News: Accreditation Survey Findings Report Includes TJC and CMS Findings

By Dean Samet, CHSP 


In July of 2009 The Joint Commission modified its Accreditation Survey Findings Report to include both TJC and Medicare requirements which were identified as being less than fully compliant at the time of survey. This is primarily for organizations that use The Joint Commission accreditation for deemed status purposes. TJC has developed crosswalks of their requirements to Medicare Conditions of Participation (CoPs) as reflected in a new report format.

Compliance News: More Days On-Site for Life Safety Code® Specialist surveyors

By Dean Samet, CHSP 

TJC is giving their Life Safety Code® Specialist Surveyors additional days on site as reported in the October 20, 2010 Joint Commission Online and November 2010 The Joint Commission Perspectives®. Effective January 1, 2011, both hospitals and critical access hospitals will have an LSC Specialist on-site from one to three extra days, depending on the size of the hospital. The LSC Specialist surveyors will be assessing compliance against both Life Safety (LS) and Environment of Care (EC) chapters. Fire safety equipment and fire safety building features standard EC.02.03.05 and emergency power systems standard EC.02.05.07 will be particular areas for review and discussion as they have historically ranked as some of the more challenging standards with which to comply. The extra days should result in a more thorough and enhanced LS and EC assessment and opportunity for additional educational training.

Power Play: NFPA Updates Standards to Improve Emergency Systems

By David Stymiest, P.E., FASHE, CHFM

The National Fire Protection Association recently published the latest editions of NFPA 110 (Standard on Emergency Power Supplies) and NFPA 111 (Standard on Stored Electrical Energy Emergency and Standby Power Systems), each of which features changes of vital interest to health facility professionals.

It is unlikely that the 2010 editions of these standards, for which the Technical Committee (TC) on Emergency Power Supplies has primary responsibility, will be imposed on accredited health facilities right away. Both the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) invoke earlier editions that are mandatory references through the 2000 NFPA 101 Life Safety Code^®.


Read entire article here: Power Play

Compliance News: TJC Infection Control Standards for Medical Equipment, Devices and Supplies

By Dean Samet, CHS

For 2010, The Joint Commission (TJC) has made several changes to its infection control standard IC.02.02 .01 including a new “rationale” and revisions to elements of performance EP1 and EP2 which clarify requirements to reduce the risks associated with medical equipment, devices and supplies.

According to an October 2009 The Joint Commission Perspectives article, several significant issues have emerged related to the cleaning, disinfecting and sterilizing of medical equipment, devices, and supplies.  TJC cites an example of the proper use of steam sterilizers as discussed in the July 2009 Perspectives.  Medical technology and instrumentation is a rapid and ever-changing field where new devices and new or resistant pathogens are emerging at an unprecedented rate.

Compliance News: TJC Alert on Violence Rising at Health Care Facilities

By Dean Samet, CHSP


 In a June 3, 2010 News Release, The Joint Commission introduced Sentinel Event Alert Issue 45: Preventing violence in the health care setting. Health care facilities are confronted with and facing increased rates of violent crimes including assault, rape and homicide.  TJC defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase, “or the risk thereof,” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.  Such events are called “sentinel” because they signal the need for immediate investigation and response.”

The Joint Commission’s SEA Issue 45 suggested actions follow:

Compliance News: TJC Elminates 16 Hospital EPs

By Dean Samet, CHSP



The Joint Commission eliminated 16 elements of performance (EPs) from their hospital accreditation program with a July 1, 2010 effective date, as announced in the June 9, 2010 Joint Commission Online publication.


These and other EPs went through an extensive evaluation process as part of TJC’s internal Robust Process Improvement (RPI) initiative started in mid-2008. The RPI establishes a measurement ranking scale against which all standards for all of TJC programs will purportedly be evaluated going forward. As part of this evaluation, more than 300 hospitals were invited to provide their perceptions of what constitutes a “valuable” standard and which standards they believed contributed the least value towardquality and safety.  TJC defines a valuable standard as one that: